Analysis of measurements from the first Swedish universal neonatal hearing screening program

Modelling the cost-effectiveness of a newborn hearing screening programme; usability and pitfalls

OBJECTIVE

The EUSCREEN project concerns the study of European vision and hearing screening programmes. Part of the project was the development of a cost-effectiveness model to analyse such programmes. We describe the development and usability of an online tool to enable stakeholders to design, analyse or modify a newborn hearing screening (NHS) programme.

DESIGN

Data from literature, from existing NHS programmes, and observations by users were used to develop and refine the tool. Required inputs include prevalence of the hearing impairment, test sequence and its timing, attendance, sensitivity, and specificity of each screening step. Outputs include the number of cases detected and the costs of screening and diagnostics.

STUDY SAMPLE

Eleven NHS programmes with reliable data.

RESULTS

Three analyses are presented, exploring the effect of low attendance, number of screening steps, testing in the maternity ward, or screening at a later age, on the benefits and costs of the programme. Knowledge of the epidemiology of a staged screening programme is crucial when using the tool.

CONCLUSIONS

This study presents a tool intended to aid stakeholders to design a new or analyse an existing hearing screening programme in terms of benefits and costs.

Protocol and programme factors associated with referral and loss to follow-up from newborn hearing screening: a systematic review

Background

An effective newborn hearing screening programme has low referral rate and low loss to follow-up (LTFU) rate after referral from initial screening. This systematic review identified studies evaluating the effect of protocol and programme factors on these two outcomes, including the screening method used and the infant group.

Methods

Five databases were searched (latest: April 2021). Included studies reported original data from newborn hearing screening and described the target outcomes against a protocol or programme level factor. Studies were excluded if results were only available for one risk condition, for each ear, or for < 100 infants, or if methodological bias was observed. Included studies were evaluated for quality across three domains: sample, screening and outcome, using modified criteria from the Ottawa-Newcastle and QUADAS-2 scales. Findings from the included studies were synthesised in tables, figures and text.

Results

Fifty-eight studies reported on referral rate, 8 on LTFU rate, and 35 on both. Only 15 studies defined LTFU. Substantial diversity in referral and LTFU rate was observed across studies. Twelve of fourteen studies that evaluated screening method showed lower referral rates with aABR compared to TEOAE for well babies (WB). Rescreening before hospital discharge and screening after 3 days of age reduced referral rates. Studies investigating LTFU reported lower rates for programmes that had audiologist involvement, did not require fees for step 2, were embedded in a larger regional or national programme, and scheduled follow-up in a location accessible to the families. In programmes with low overall LTFU, higher LTFU was observed for infants from the NICU compared to WB.

Conclusion

Although poor reporting and exclusion of non-English articles may limit the generalisability from this review, key influential factors for referral and LTFU rates were identified. Including aABR in WB screening can effectively reduce referral rates, but it is not the only solution. The reported referral and LTFU rates vary largely across studies, implying the contribution of several parameters identified in this review and the context in which the programme is performed. Extra attention should be paid to infants with higher risk for hearing impairment to ensure their return to follow-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03218-0.

Newborn Hearing Screening and Intervention in Children with Unilateral Hearing Impairment: Clinical Practices in Three Nordic Countries

Studies have limitedly considered children with early-identified unilateral hearing impairment (UHI), and clinical practices regarding screening, diagnostics and habilitation in this group are rarely documented. In this study, routines for newborns with UHI from screening to diagnostics and habilitation were explored in Norway, Sweden and Finland. An online survey was sent to hospitals responsible for the hearing diagnostics of children requesting information about their practices regarding congenital UHI. Responses covered 95% of the children born in the three included countries. The results revealed large variations in ways of organising healthcare and in clinical decisions regarding hearing screening, diagnostics and habilitation of children with congenital UHI. Finally, implications for policy making and research are also discussed.

Cost-Effectiveness of Neonatal Hearing Screening Programs: A Micro-Simulation Modeling Analysis

Supplemental Digital Content is available in the text.

Early detection of neonatal hearing impairment moderates the negative effects on speech and language development. Universal neonatal hearing screening protocols vary in tests used, timing of testing and the number of stages of screening. This study estimated the cost-effectiveness of various protocols in the preparation of implementation of neonatal hearing screening in Albania.

Detection of hearing loss in newborns: Definition of a screening strategy in Bogotá, Colombia

OBJECTIVE

To describe the results from the hearing screening protocol adopted in a Hospital in Colombia emphasizing the importance of performing screening on an outpatient basis, when the newborn is more than 24 h old.

METHODS

A prospective study at Hospital Universitario San Ignacio in Bogota, Colombia was carried out, from May 1st, 2016 to Nov 30^th, 2017, the study sample included 2.088 newborns examined using transient otoacoustic emissions.

RESULTS

We obtained written consent from the parents of 1.523 newborns and 24 individuals (1.6%) failed the first stage of the screening, nine cases unilateral and 15 bilateral. A total of nine neonates (0,6%) failed the second screening test, six cases unilateral and three bilateral. Four (0,3%) did not return to the second test. Our false altered screening rate was 0.7%.

CONCLUSIONS

In a developing country with limited human and economic resources, in which newborn early discharge is the norm, a newborn hearing screening program linked to infants' check-ups, that uses otoacoustic emissions after 48 h of life, seems a feasible option compare to the standard US protocol aiming to conduct hearing screening prior to discharge.

Newborn hearing screening protocols and their outcomes: A systematic review

OBJECTIVE

To conduct a review of the most current research in objective measures used within newborn hearing screening protocols with the aim of exploring the actual protocols in terms of the types of measures used and their frequency of use within a protocol, as well as their outcomes in terms of sensitivity, specificity, false positives, and false negatives in different countries worldwide.

METHODS

A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Electronic databases such as PubMed, Google Scholar and Science Direct were used for the literature search. A total of 422 articles were identified, of which only 15 formed part of the current study. The 15 articles that met the study's criteria were reviewed. Pertinent data and findings from the review were tabulated and qualitatively analysed under the following headings: country; objective screening and/or diagnostic measures; details of screening protocol; results (including false positive and negative findings, sensitivity and/or specificity), conclusion and/or recommendations. These tabulated findings were then discussed with conclusions and recommendations offered.

RESULTS

Findings reported in this paper are based on a qualitative rather than a quantitative analysis of the reviewed data. Generally, findings in this review revealed firstly, that there is a lack of uniformity in protocols adopted within newborn hearing screening. Secondly, many of the screening protocols reviewed consist of two or more tiers or stages, with transient evoked otoacoustic emissions (TEOAEs) and automated auditory brainstem response (AABR) being most commonly used. Thirdly, DPOAEs appear to be less commonly used when compared to TEOAEs. Lastly, a question around routine inclusion of AABR as part of the NHS protocol remains inconclusively answered.

CONCLUSIONS

There is sufficient evidence to suggest that the inclusion of AABR within a NHS programme is effective in achieving better hearing screening outcomes. The use of AABR in combination with OAEs within a test-battery approach or cross-check principle to screening is appropriate, but the inclusion of AABR to facilitate appropriate referral for diagnostic assessment needs to be systematically studied.

Universal newborn hearing screening: methods and results, obstacles, and benefits

The incidence of sensorineural hearing loss ranges from 1 to 3 per 1,000 live births in term healthy neonates, and 2-4 per 100 in high-risk infants, a 10-fold increase. Early identification and intervention with hearing augmentation within 6 mo yields optimal effect. If undetected and without treatment, significant hearing impairment may negatively impact speech development and lead to disorders in psychological and mental behaviors. Hearing screening programs in newborns enable detection of hearing impairment in the first days after birth. Programs to identify hearing deficit have significantly improved over the two decades, and their implementation continues to grow throughout the world. Initially based on risk factors, these programs identified only 50-75% of infants with hearing loss. Current recommendations are to conduct universal hearing screening in all infants. Techniques used primarily include automated auditory brainstem responses and otoacoustic emissions that provide noninvasive recordings of physiologic auditory activity and are easily performed in neonates and infants. The aim of this review is to present the objectives, benefits, and results of newborn hearing screening programs including the pros and cons of universal vs. selective screening. A brief history and the anticipated future development of these programs will also be discussed.

Evaluation of universal newborn hearing screening in South African primary care

BACKGROUND

Universal Newborn Hearing Screening (UNHC) is the gold standard toward early hearing detection and intervention, hence the importance of its deliberation within the South African context.

AIM

To determine the feasibility of screening in low-risk neonates, using Otoacoustic Emissions (OAEs), within the Midwife Obstetric Unit (MOU) three-day assessment clinic at a Community Health Centre (CHC), at various test times following birth.

METHOD

Within a quantitative, prospective design, 272 neonates were included. Case history interviews, otoscopic examinations and Distortion Product OAEs (DPOAEs) screening were conducted at two sessions (within six hours and approximately three days after birth). Data were analysed via descriptive statistics.

RESULTS

Based on current staffing profile and practice, efficient and comprehensive screening is not successful within hours of birth, but is more so at the MOU three-day assessment clinic. Significantly higher numbers of infants were screened at session 2, with significantly less false-positive results. At session 1, only 38.1% of the neonates were screened, as opposed to more than 100% at session 2. Session 1 yielded an 82.1% rate of false positive findings, a rate that not only has important implications for the emotional well-being of the parents; but also for resource-stricken environments where expenditure has to be accounted for carefully.

CONCLUSION

Current findings highlight the importance of studying methodologies to ensure effective reach for hearing screening within the South African context. These findings argue for UNHS initiatives to include the MOU three-day assessment to ensure that a higher number of neonates are reached and confounding variables such as vernix have been eliminated.

Performance and characteristics of the Newborn Hearing Screening Programme in England: The first seven years

Objective: To assess the performance of the universal newborn hearing screen in England. Design: Retrospective analysis of population screening records. Study sample: A total of 4 645 823 children born 1 April 2004 to 31 March 2013. Results: 97.5% of the eligible population complete screening by 4/5 weeks of age and 98.9% complete screening by three months of age. The refer rate for the 12/13 birth cohort is 2.6%. The percentage of screen positive (i.e. referred) babies commencing follow up by four weeks of age and six months of age is 82.5% and 95.8% respectively. The yield of bilateral PCHL from the screen is around 1/1000. For bilateral PCHL in the 12/13 birth cohort the median age is nine days at screen completion, 30 days at entry into follow up, 49 days at confirmation, 50 days at referral to early intervention, and 82 days at hearing-aid fitting. Conclusion: The performance of the newborn hearing screening programme has improved continuously. The yield of bilateral PCHL from the screen is about 1/1000 as expected. The age of identification and management is well within the first six months of life, although there remains scope for further improvement with respect to timely entry into follow up.

Inventory of current EU paediatric vision and hearing screening programmes

OBJECTIVE

To examine the diversity in paediatric vision and hearing screening programmes in Europe.

METHODS

Themes for comparison of screening programmes derived from literature were used to compile three questionnaires on vision, hearing, and public health screening. Tests used, professions involved, age, and frequency of testing seem to influence sensitivity, specificity, and costs most. Questionnaires were sent to ophthalmologists, orthoptists, otolaryngologists, and audiologists involved in paediatric screening in all EU full-member, candidate, and associate states. Answers were cross-checked.

RESULTS

Thirty-nine countries participated; 35 have a vision screening programme, 33 a nation-wide neonatal hearing screening programme. Visual acuity (VA) is measured in 35 countries, in 71% of these more than once. First measurement of VA varies from three to seven years of age, but is usually before age five. At age three and four, picture charts, including Lea Hyvarinen, are used most; in children over four, Tumbling-E and Snellen. As first hearing screening test, otoacoustic emission is used most in healthy neonates, and auditory brainstem response in premature newborns. The majority of hearing testing programmes are staged; children are referred after 1-4 abnormal tests. Vision screening is performed mostly by paediatricians, ophthalmologists, or nurses. Funding is mostly by health insurance or state. Coverage was reported as >95% in half of countries, but reporting was often not first-hand.

CONCLUSION

Largest differences were found in VA charts used (12), professions involved in vision screening (10), number of hearing screening tests before referral (1-4), and funding sources (8).

Effects of changes in click-evoked otoacoustic emission (CEOAE) pass criteria, as used in the English newborn hearing screening program, on screening outcome

OBJECTIVE

There were two objectives, firstly what effect does a change in the pass criteria of a click-evoked otoacoustic emission (CEOAE) newborn hearing screen have on the number of cases of significant hearing impairment detected by follow up diagnostics, and secondly how does this change affect the screen pass rate?

DESIGN

Changes in the pass criteria were: reduction in the signal-to-noise ratio (SNR); reduction in the minimum signal level (MSL); inclusion of the 1-kHz half-octave band; reduction from two to a single half-octave band.

STUDY SAMPLE

Data from three screening sites was used within the English newborn hearing screening program from the period 2002 to 2006, with a total number of births of about 40,000. There were 42 bilateral and 43 unilateral cases of significant hearing impairment.

RESULTS

No effect on the number of cases detected by follow up diagnostics was observed when: (1) SNR was reduced to a minimum of 5 dB; (2) MSL was reduced to -10 dB SPL; and (3) the 1-kHz band was included. With all these changes the percentage pass rate improved by 0.36%.

CONCLUSIONS

The current choice of SNR and MSL criteria appears robust. Only a small increase in pass rate is possible without affecting case detection.

Potencial Evocado Auditivo de Estado Estável com estímulo de ruído branco modulado em amplitude em triagem auditiva neonatal

OBJETIVO: verificar a utilização do estímulo ruído branco, modulado em amplitude, no exame de Potencial Evocado Auditivo de Estado Estável (PEAEE). MÉTODO: foram avaliados 30 neonatos e lactentes, na Maternidade do Hospital das Clínicas da UFPE, que realizaram os exames de Emissões Otoacústicas Transientes (EOAT) e PEAEE, com ruído branco de amplitude modulada. RESULTADOS: para o exame de PEAEE, sugere-se que a intensidade ideal para o ponto de corte seja 50 dB NPS, para os casos com passa na triagem auditiva, com o exame de EOAT. CONCLUSÃO: o exame de PEAEE, realizado com ruído branco, modulado em amplitude, parece ser promissor como ferramenta de triagem auditiva. Entretanto, estudos são necessários para observar a relação entre os limiares das respostas auditivas de estado estável utilizando-se tons puros e ruído branco, a fim de melhor elucidar e definir parâmetros e protocolos de sua utilização.

Interdisciplinary approach to design, performance, and quality management in a multicenter newborn hearing screening project. Discussion of the results of newborn hearing screening in Hamburg (part II)

Previously presented results of the newborn hearing screening in Hamburg and the perspectives are subsequently discussed. Minimum standards referring a participation of 95% of the neonates and a fail rate of less than 4% hearing-impaired children at the primary screening are fulfilled in Hamburg. Systematic screening of newborn hearing by an interdisciplinary approach provides early identification and intervention for children with permanent unilateral and bilateral hearing loss. But a newborn hearing screening on a voluntary basis alone cannot be maintained in the long run. Further, an anonymous data collection is not sufficient in regard to an uninterrupted tracking of conspicuous and unscreened neonates. A lost-to-follow-up rate of 31.3% at primary screening in Hamburg is much too high and emphasizes the need for a public health approach to a population-based newborn hearing screening with an elaborate and name-based tracking system. The legislation and implementation of a nationwide newborn hearing screening program in Germany and the association of German newborn hearing screening centers are highlighting long efforts of hearing professionals. But the implementation of a newborn hearing screening only makes sense if there exists an efficient tracking system. Sad to say, we are still a long way from the implementation of such a tracking system.

National newborn hearing screening program in Turkey: struggles and implementations between 2004 and 2008

OBJECTIVE

In this review, we have presented the data of our National Newborn Hearing Screening Program (NNHSP) with total 764,352 newborns those screened in last five years.

METHODS

National Newborn Hearing Screening Program (NNHSP) has been conducted in Turkey since the year 2003. National Newborn Hearing Screening Program (NNHSP) had begun at the end of 2003 only in 1 center. After birth, in the third day, Transient Evoked Otoacoustic Emissions (TEOAEs) test criteria and if necessary, auditory brain response (ABR) testing evaluation methods were applied to newborn. The children diagnosed with hearing loss were further referred for advanced treatment and rehabilitation to advanced audiologic centers.

RESULTS

After five years of carrying out the program (between 2004 and 2008) a total number of 764,352 newborns were screened for hearing impairment. In the year 2008, National Newborn Hearing Screening Program (NNHSP) had given the chance for 2136 children with various types of hearing loss (320 with unilateral and 417 with bilateral hearing loss) to detect and refer to more experienced centers for further treatment.

CONCLUSIONS

Our results indicate that the necessity of newborn hearing screening is an indispensable issue. We have been targeted to develop National Newborn Hearing Screening Program (NNHSP) till given chance to access for every newborn in Turkey in next five years.

Polish universal neonatal hearing screening program-4-year experience (2003-2006)

OBJECTIVE

The aim of this paper is to share our experience and observations in running the Universal Neonatal Hearing Screening Program on a national level, present results and indicate some problems that have arisen during these 4 years.

METHODS

Polish Universal Neonatal Hearing Screening Program started back in 2002 in all neonatal units in Poland. Implemented testing methods consisted of test of transient evoked otoacoustic emission (TEOAE) performed in all new born children in their first 2-3 days of life and auditory brainstem response testing (ABR) conducted on children, who did not meet the TEOAE pass criteria. Additional questionnaire registered information on ototoxic drugs and family history of hearing impairment in every newborn. Diagnosed children were further referred for treatment and rehabilitation.

RESULTS

After 4 years of running the program (between 2003 and 2006) a total number of 1,392,427 children were screened for hearing impairment, what stands for 96.3% of all delivered babies, registered in Poland. The screening program enabled to identify and refer for further treatment 2485 children with various types of hearing loss, 312 with profound (0.02% of population) and 145 with severe sensorineural hearing loss (0.11% of population).

CONCLUSIONS

Our results indicate the accuracy of newborn hearing screening which remain an issue. Although improvement is needed in both intervention systems and diagnostic follow-up of hospitals, the Polish Universal Neonatal Hearing Program fully has achieved the main goal, the identification and treatment of hearing impaired children.